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4
More Professionalism, Less Regulation: A Response

Lonnie R. Bristow

On behalf of the American Medical Association (AMA), I would like to congratulate the Institute of Medicine (IOM) for this important report (IOM, 1990). There is little doubt that Americans, including the elderly, generally receive high-quality medical care. Nevertheless, improvement in the quality of medical care is always possible, and we welcome effective strategies to accomplish this goal.

We have reviewed the IOM's report and have found the principles in that report to be generally consistent with existing AMA policies. In addition, the report proposes a number of changes in the Medicare review process that are also consistent with our long-standing goals, including greater emphasis on quality rather than cost concerns, on professional self-regulation, and on educational (as opposed to punitive) uses of review. I can find absolutely nothing with which to disagree in Dr. Cooney's initial statements (Cooney, 1991).

PROGRAMMATIC CONSIDERATIONS

We do, however, disagree with some of the programmatic activities recommended in the IOM's report. For example, we believe that before considering recommendations regarding the complete elimination of utilization review as a component of Peer Review Organization (PRO) review activities, it is important to determine where and how utilization review will be conducted because, properly done, it does have value. Although there are many shortcomings in the utilization review activities of PROs, the utilization review processes used by PROs generally have been superior to those used by carriers.

The IOM's report calls for an expansion of PRO quality review activities with strong emphasis on data analysis and outcomes assessment. In assessing



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Medicare: New Directions in Quality Assurance 4 More Professionalism, Less Regulation: A Response Lonnie R. Bristow On behalf of the American Medical Association (AMA), I would like to congratulate the Institute of Medicine (IOM) for this important report (IOM, 1990). There is little doubt that Americans, including the elderly, generally receive high-quality medical care. Nevertheless, improvement in the quality of medical care is always possible, and we welcome effective strategies to accomplish this goal. We have reviewed the IOM's report and have found the principles in that report to be generally consistent with existing AMA policies. In addition, the report proposes a number of changes in the Medicare review process that are also consistent with our long-standing goals, including greater emphasis on quality rather than cost concerns, on professional self-regulation, and on educational (as opposed to punitive) uses of review. I can find absolutely nothing with which to disagree in Dr. Cooney's initial statements (Cooney, 1991). PROGRAMMATIC CONSIDERATIONS We do, however, disagree with some of the programmatic activities recommended in the IOM's report. For example, we believe that before considering recommendations regarding the complete elimination of utilization review as a component of Peer Review Organization (PRO) review activities, it is important to determine where and how utilization review will be conducted because, properly done, it does have value. Although there are many shortcomings in the utilization review activities of PROs, the utilization review processes used by PROs generally have been superior to those used by carriers. The IOM's report calls for an expansion of PRO quality review activities with strong emphasis on data analysis and outcomes assessment. In assessing

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Medicare: New Directions in Quality Assurance the performance of PROs to date in detecting and addressing quality problems, it is helpful to keep in mind the relatively early stage of PRO activities in this area. Unfortunately, PROs too often have directed their attention primarily to utilization and cost containment rather than quality assurance. Therefore, we are pleased that quality review is becoming a more important focus of PROs, and we need to recognize that many of the techniques to identify cases of possible quality problems are still in their infancy. Providing quality medical care is an enormously complex process in which many subjective as well as objective issues must be considered. For example, is there medical certainty in the relevant clinical area? What treatment options are available? What technology or specialized facilities are available? What are the patients expectations and are those expectations reasonable? What quality-of-life issues should be considered? What other factors should be integrated in the individual treatment decision? Although some of these issues can be quantified, many cannot. In essence I am saying that there are precious few all black and all white decisions that are made. There are, instead, a great many gray decisions that have to be made. We agree that ongoing research is essential to identify and improve techniques to collect and analyze data. Yet the limitations inherent in data analysis must be kept in mind. Data analysis will be an important adjunct to, rather than a substitute for, clinical judgment. Improved data and more sophisticated data analysis will be useful to quality assurance activities. However, the data will never substitute for clinical judgment or true medical peer review. Physicians must continue to have the flexibility to tailor medical care to meet individual patient needs. PRACTICE PARAMETERS I would like particularly to commend the IOM's report for its emphasis on the role of practice parameters in improving quality and assuring appropriate utilization. Physician organizations have played a key role in the development of such practice parameters. Eight physician organizations had already developed certain practice parameters by 1980. Recently I heard an economist in another city discussing practice parameters, and he was recommending to a group of physicians that they really ought to use them. He presented the subject almost as though economists had invented practice parameters. At this time in 1990, 26 physician organizations have developed useful parameters, and at least 10 additional organizations of physicians are actively engaged in the development of other practice parameters. Effective practice parameters are an important mechanism to improve quality. For example, the parameters for cardiac pacemaker implantation

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Medicare: New Directions in Quality Assurance developed by the American College of Cardiology have already contributed to significant improvement in the appropriate utilization of pacemakers. Implementation of parameters for intraoperative monitoring developed by the American Society of Anesthesiologists has already significantly reduced the occurrence of hypoxic injuries in patients during surgery. In addition to their direct benefit to physicians, practice parameters will also provide a rational basis for the development of review criteria for quality assurance programs. AMERICAN MEDICAL ASSOCIATION (AMA) GUIDELINES FOR QUALITY ASSURANCE Because of our deep commitment to improving the quality of medical care, the AMA has developed a set of guidelines for quality assurance that should be included in any medical peer review system. We have shared those guidelines with the Institute of Medicine during the preparation of its report, and we are extremely pleased to find that many of these principles are incorporated in the IOM's report. Five of the key guidelines are as follows: The general policies utilized in any quality assurance system should be developed and agreed upon by the physicians whose performance will be scrutinized and should be objectively and impartially administered. Such involvement and objectivity are critical to assuring continued physician participation and cooperation. To the degree possible, quality assurance systems should be structured to recognize care of high quality as well as to correct instances of deficient practice. Quality assurance systems should explore methods to identify and recognize those treatment methodologies or protocols that consistently contribute to improved patient outcomes, and information on such results should be communicated to the medical community. Feedback mechanisms should be established to monitor and document needed changes in practice patterns. You have heard many speakers say physicians want that sort of information, and that's absolutely correct. Linkages between quality assurance activities and quality assessment systems should allow the very important assessment of the effectiveness of any remedial activities that have been instituted. Quality assurance systems should make available the appropriate educational resources required to effect desired practice modifications. It does little good to inform physicians about what needs to be done unless one provides the resources required to put that information in a useful and practical package. Emphasis should be placed on education and modification of unacceptable practice patterns rather than on sanctions. The initial thrust of any

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Medicare: New Directions in Quality Assurance quality assurance activity should be toward helping practitioners correct deficiencies found in knowledge, skills, or technique. RESEARCH AND PEER REVIEW We believe strongly that additional research should be conducted to improve quality assessment and quality assurance. Well-conducted research will improve quality assurance programs and provide a much better scientific basis for clinical management decisions. We are also staunch advocates of effective medical peer review being an essential component of quality assurance. True medical peer review is the review of the clinical performance of physicians by other physicians of like training and specialty. We recognize the need for accountability in our actions and want that accountability to be based upon appropriate medical peer review. CONCLUSION In conclusion, although Americans, including the elderly, in general receive high quality medical care, we must continue to expand our efforts to improve the quality of medical care. Improved systems of quality assurance are an important part of that effort. However, strategies to improve quality assurance must acknowledge the complexities inherent in the care of patients and the enormous variability that occurs among patients, in their clinical status as well as in their preferences. Although data analysis and outcomes assessment will be important, data analysis will never substitute for clinical judgment or for medical peer review. Physicians have long played an active role in efforts to improve the quality of medical care, and future efforts to improve quality assurance must involve physicians and physician organizations in every aspect of the planning and implementation of quality assurance systems. Again, we applaud the IOM for its effort. The AMA looks forward to working with the IOM and others as the recommendations contained in the report are further evaluated, and to the extent that they conform to the five precepts previously articulated, you will find us very willing participants with you. Finally, although quality assurance programs are essential, quality assurance systems will never substitute for or replace the one essential component of quality medical care: well-informed, caring physicians addressing the unique needs of individual patients to produce the optimal possible improvement in that patient's physiological status, physical function, emotional and intellectual performance, and comfort.

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Medicare: New Directions in Quality Assurance REFERENCE Cooney, L.M., Jr. More Professionalism, Less Regulation: The Committee View. Pp. 18-22 in Medicare: New Directions in Quality Assurance. Donaldson, M.S., Harris-Wehling, J., and Lohr, K.N., eds. Washington, D.C.: National Academy Press, 1991. Institute of Medicine. Medicare: A Strategy for Quality Assurance. Volumes I and II. Lohr, K.N., ed. Washington, D.C.: National Academy Press, 1990.